2020-2021 REQUEST FOR RECONSIDERATION
B
ASED ON EXTENUATING CIRCUMSTANCES
Student's Name ___________________________________ SS# or ID # _____________________________________
Address ____________________________________________________ Cell phone___________________________
1. Income earned in 2018 does not accurately reflect the student's and/or spouse's, and/or parents' current income
circumstances for one for the following reasons: (check all that apply)
Independent Student
____ a. loss of employment or change of employment status for student/spouse;
____ b. divorce/separation or death of a spouse;
____ c. loss of untaxed income;
____ d. disability of student/spouse;
____ e. unusual medical/dental bills or handicapped related expenses;
____ f. one-time income; (see item #3 below)
____ g. other unusual debt/expenses.
Dependent Student
____ h. parents' or student’s loss of employment or change in employment status;
____ i. divorce/separation or death of a parent;
____ j. loss of untaxed income (Social Security benefits, pension, etc);
____ k. disability of a parent;
____ l. unusual medical/dental bills or handicapped related expenses;
____ m. one-time income; (see item #3 below)
____ n. other unusual debt/expenses.
2. If (a, b, c, d) or (h, i, j, or k) is checked above, please complete the following chart using 2018 income
INCOME* Provide copy of 2019 Federal Tax return or 2019 yearly income documents:
Student Spouse or Parent
Wages, salaries, tips (Include severance pay, disability payments, etc.
Other taxable income (Unemployment Compensation, Worker’s Comp, Etc.)
Untaxed social security benefits
Public Assistance
Child Support Received
Other Untaxed Income
TOTAL INCOME
*If you or your parents are divorced or separated, give only your information or the information of the custodial parent.
*If loss of income was due to the death of a spouse or parent, give only your information or the information of your
surviving parent.
3. If (f) or (m) is checked, identify the source of income and explain how the funds were spent or invested. Explain below.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
CERTIFICATION:
All of the information on this form and supporting documents
is true and complete to the best of my knowledge.
_____________________________________________________
Student's Signature Date
Yes No
______________________
Financial Aid Officer Date
